Dr. Samuel Metz, an anesthesiologist in Oregon, has a letter in the August 27 New York Times arguing for a single payer system in the US Several responses follow.

I wanted to write about the exchange especially for European friends I spoke with on a recent trip. They were universally puzzled – “how can it be that you in the States don't have health care for all?”

Dr. Metz is obviously correct. No sane society designing a system from scratch would create the cockeyed US non-system. The hodge podge we have is a result of history (making health insurance an employment benefit during World War II) and theology (our faith in free markets even when experience tells us they don't work).

To help explain – to myself and others – why we in the US are so resistant to doing the obvious right thing, here's one of the responses to Metz, with my comments interlaced in bold italics:

Dr. Metz’s call for single-payer national health care imposes costs on taxpayers rather than directly on those being served. Note the assumption that shared responsibility for health care is unjust. Would the writer do away with police, fire depart-ments and public education because they “impose costs on taxpayers” rather than “directly on those being served”? Patients are not charged more for services they value the most or are more costly to provide. If I want more costly clothes or a sports car, it's clear that I should be responsible for financing my own preferences. But if you get cancer, would it be right for me to say “the chemotherapy is costly, and you value it most, so you should pay for it yourself”? Extending the model of optional purchases to chemotherapy for cancer or appendectomy for appendicitis turns health care needs into consumer whims. But needs and whims are not the same! Tax bills simply rise in sync with something else like income, property or sales. Here the writer assumes the single payer is passive and helpless in relation to prices and service patterns. That's actually how our “free market” system behaves! Single payer systems, and other forms of universal coverage, are much more active in managing the cost trend than the invisible hand of the US market is.

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It takes no leap of faith to understand how this will affect demand for health care. Anyone who has dined at a fixed-cost food buffet knows the outcome of not directing price with food portions. Comparing medical care to “a fixed-cost food buffet” again shows the writer's underlying framework – health care is like hot dogs, a trivial matter of consumer whim. Patients who don't need chemotherapy or appendectomy don't ask for these services just because they're paid for, even if they do eat an extra hot dog at the buffet. And there's no reason that a single payer system couldn't apply value-based principles, with full coverage of needed services for which there are no alternatives, but partial or no coverage for low value services, or services that have less costly equivalents.

It is tempting to believe that government will fairly and efficiently make these choices for us, but experience suggests otherwise. The writer is flat-out wrong. Citizen satisfaction is significantly higher in countries with publicly financed universal coverage, and health outcomes are as good or better. He's revealing his theology – blind faith that governments are always bad/markets are always good. Dr. Metz appears to anticipate this problem given his suggestion that Congress’s power to tax is indisputable and so government will predictably raise taxes to pay for growing demand for health care.

MICHAEL L. MARLOW

San Luis Obispo, Calif., Aug. 25, 2011The writer is a professor of economics at California Polytechnic State University, San Luis Obispo.

Professor Marlow is an accomplished scholar. The fact that such a well-informed person subscribes to the political and economic theology his letter evinces shows why the US, alas, is not yet ready to give serious consideration to publicly financed, not-for-profit health care. If Vermont's single payer program succeeds, that will chip away at our reflexive anti-government/anti-communitarian approach to the health system.

All kinds of economic interests – the “medical-industrial complex” – favor the status quo, but the faith-based beliefs Professor Marlow's letter exemplifies are the largest impediment to steering our system in the direction virtually every other developed country has taken.

In talking about US health care theology with my European friends I quoted Schopenhauer: “As a serious conviction, it could be found only in a madhouse; as such it would then need not so much a refutation as a cure.”

Jim Sabin is a clinical professor in the departments of Population Medicine and Psychiatry at Harvard Medical School. He has written two books about health system ethics: 'Setting Limits Fairly: Learning to Share Resources for Health,' and 'No Margin, No Mission: Health-Care Organizations and the Quest for Ethical Excellence.'

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